II. Epidemiology

  1. Incidence: 1 to 1.5 per 100,000
  2. Cerebroarterial Dissections (Carotid Artery and Vertebral Artery) are uncommon (<2%) causes of Ischemic CVA
  3. Age
    1. Younger patients account for up to 25% of Vertebral Dissection related Ischemic CVA
    2. Peak Incidence age 50-60 years
  4. Gender
    1. Women are affected at a younger age than men

III. Pathophysiology

  1. Vertebral Artery Dissection most commonly occurs with compression at one of two foramina
    1. Cervical foramen at C1-2
    2. Transverse foramen at C5-6
  2. Vertebral Artery media tear (middle muscular, arterial layer) allowing blood intrusion into arterial wall
    1. Resulting intramural thrombus occludes vessel with risk of CVA

V. Types

  1. Ischemic Vertebral Artery Dissection
    1. Resulting cerebral ischemia or infarction
    2. Many dissections heal spontaneously and occluded vessels may be compensated by opposite Vertebral Artery
  2. Rupture of Intradural Vertebral Artery dissecting aneurysm (hemorrhagic)
    1. Subarachnoid Hemorrhage
    2. Unstable with high risk of recurrent bleeding (70% of cases, most within first week, and mortality 47%)

VI. Findings

  1. Extracranial Vertebral Artery Dissection (primarily at C1-2)
    1. Occipitocervical region severe pain
      1. Unilateral Neck Pain and Headache
    2. Vertebrobasilar Ischemia or Infarction Symptom
      1. Dizziness
      2. Vertigo
      3. Diplopia
      4. Ataxia
      5. Dysarthria
    3. Vertebrobasilar Infarction
      1. Cerebellar infarction
      2. Spinal Cord Infarction
        1. See Spinal Cord Syndrome
      3. Wallenberg Syndrome (lateral Medullary ischemia)
        1. Dysmetria, Ataxia and ipsilateral Hemiplegia
  2. Intracranial Vertebral Artery Dissection
    1. Subarachnoid Hemorrhage in 50% of cases
    2. High rebleeding rate, poor prognosis, high mortality
    3. Responsible for up to 10% of non-Traumatic Subarachnoid Hemorrhage
    4. May be minor in some cases

VII. Imaging

  1. MR Angiogram
    1. Has largely replaced CT Angiogram as gold standard, with similar efficacy
  2. CT Angiogram
    1. As with MRA, CT angiogram has high Test Sensitivity

VIII. Prognosis

  1. Extracranial Vertebral Artery Dissection
    1. No deficit 50%
    2. Mild deficit 21%
    3. Moderate to severe deficit 25%
    4. Mortality 4%
  2. Intracranial Vertebral Artery Dissection
    1. Associated with severe neurologic deficits

IX. Management

  1. Anticoagulation (unless contraindicated, e.g. Hemorrhage)
    1. Intravenous Heparin, then
    2. Oral Anticoagulant
  2. Surgical interventions
    1. Endovascular procedures
    2. Vascular or Neurosurgery

X. References

  1. Hussein and Leiman (2022) Crit Dec Emerg Med 36(8): 4-8
  2. Park (2008) J Korean Neurosurg Soc 44:109-15 [PubMed]

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